CLINIC CANCELLATION REQUEST RESIDENT’S NAME TODAY’S DATE DATE REQUESTED

ACTUALIZACION EN NUTRICION CLINICA Y DIETOTERAPIA 20ª EDICIÓN
CLINICALLY RELEVANT ANATOMY 123 ULNAR NERVE ENTRAPMENT
LONG ISLAND BHM CONCURRENT CLINICAL PLEASE COMPLETE

PSYCHOLOGY AND CLINICAL LANGUAGE SCIENCES UNIVERSITY OF READING
(INSERT AGENCY NAME) REPRODUCTIVE HEALTH PROGRAM CLINICAL POLICIES AND
0 CLINICS ARE FREE TO INCOMEELIGIBLE INDIVIDUALS CLINICS MARKED

Continuity Clinic Cancellation Request

Clinic Cancellation Request


Resident’s Name

Today’s Date

Date Requested Off

Brief Reason for Requesting Cancellation

Clinic Site [ ] UCIMC [ ] LBVAMC

Clinic Attending


Detailed Explanation of the Rationale for the Cancellation of a Clinic Session. Include the reason for cancellation and any relevant travel plans, relationships of individuals involved in the request, reason why this cannot be delayed.

Number of Prior Approved Clinic Cancellations

Signature of Program Coordinator

Name of the Resident Covering Your Clinic

Signature of the Resident Covering Your Clinic

Name of Your Clinic Director

Signature of the Clinic Director

Name of the Chief Resident(s) at the affected sites

Signature(s) of the Chief Resident

Program Director

Program Director’s Signature

Schedule changes which involve clinic cancellation for any reason (including presentation at meetings or any other academic activity) will only be considered if submitted in writing on the Clinic Cancellation Form (available on the website under “Forms”). The Form must be submitted to the Program Director 60 days prior to the beginning of the first day of the first rotation affected by the change. The resident must find a colleague to see all scheduled patients in his or her continuity clinic and obtain the signature of that colleague and the director of the clinic affected by the change. (Patients will not be cancelled or moved.)The resident must also obtain the signature of the chief residents of the affected institution or institutions affected by the cancellation and the signature of the Program Coordinator specifying how many prior cancellations have occurred. Changes are not approved and schedule changes cannot be made until approved by the Program Director. These requests will be considered on an individual basis, taking into account the merit of the request and its effect on the program. Residents may not cancel more than one clinic per year nor more than two over the 36 months of the Residency.


006-17%20Clinical%20Psychiatrist%20%20Board%20%20037869
1 COURSE TITLE CLINICAL PRACTICUM IN AUDIOLOGY 2 2
1 NEONATAL RESPIRATORY DISTRESS INCLUDING CPAP CLINICAL LEARNING RESOURCE


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